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Evidence-Based Update on Chest Tube Management

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Evidence-Based Update on Chest Tube Management Evidence-based update on chest tube management Is your practice current? By Randelle I. Sasa, MA, RN-BC, CMSRN, CCRN CHEST thoracotomy tubes CTT insertion (CTTs) have been around for When a provider orders a centuries, but not until the CTT, your responsibilities in- late 1950s did they become clude verifying patient iden- standard of care for treating tification, ascertaining that empyema, pneumothorax, informed consent has been hemo thorax, hemopneumo - obtained (except in emer- thorax, and pleural effusion. gencies), and determining CTTs can be life-saving, but patient understanding of the only if managed based on pro cedure. Explain the pro- current best evidence. cedure to the patient, assess his or her com pre hen sion, Breathing basics answer questions within Understanding CTTs begins your purview, and allow the with understanding how breathing case is tension pneumothorax, patient to express his or her anxi- works. Ventilation, a two-part which is characterized by progres- ety. Taking these steps will im- process, begins with inhalation. sive accumulation and trapping of prove patient cooperation during The chest cavity expands, mostly air in the pleural cavity, causing the procedure. through dia phragm contraction, low- pressure buildup that obliterates Hemorrhage is a potential compli- ering pressure inside the chest cav- space for adjacent structures (lungs, cation of chest tube placement, so ity and effectively creating suction. vena cava, and heart). CTTs drain review the patient’s medications Air moves from the atmosphere of fluid and air in the pleural cavity (look for heparin, warfarin, apixa- greater pres sure and into the tho- to promote lung re-expansion. ban) and coagulation profile (activat- racic cavity, where pressure is Now that you understand the ed partial prothrombin time, interna- lower. This is negative pressure ven- phys i ology, you’re ready to dive in- tional normalized ratio, platelets, and tilation. The second part of ventila- to the details of CTT management. fibrinogen). Anticoagulant use is a tion, exhalation, is passive as the relative contraindication to CTT in- diaphragm and other respiratory sertion, but the provider will weigh muscles resume their resting config- the risks and benefits. CNE uration. The decreased size of the 1.66 contact You’ll also be involved in gather- lungs reverses the pressure gradi- hours ing supplies, administering antibiotic ent, and air is forced out into the at- and pain prophylaxis as ordered, as- mosphere. LEARNING OBJECTIVES sisting with selecting and imaging the Between the outer lining of the 1. Describe patient care related to in- insertion site, positioning the pa- lungs and the inner chest wall lies sertion of a chest thoracotomy tube tient, ensuring sterile technique, the pleural space, which normally (CTT). securing≥ the tube, and confirming is lubricated by pleural fluid in the 2. Discuss management of patients placement. amount of 0.2 mL/kg (10 to 20 mL with a CTT in place. Gather supplies: As ordered by for average-size adults). When pleur - 3. Identify CTT complications. the provider, prepare the CTT in- al integrity is breached, excess The author and planners of this CNE activity have sertion tray, tube, and drainage blood, serous fluid, or air accumu- disclosed no relevant financial relationships with system. (See Small bore or large any commercial companies pertaining to this activ- lates. The body can handle small ity. See the last page of the article to learn how to bore?) Set up chest drainage units amounts of extra pleural fluid or earn CNE credit. (CDUs) per the manufacturer’s rec- air, but large amounts (≥ 300 mL) ommendations. For underwater impede ventilation. An extreme seal CDUs, the most important prep - 10 American Nurse Today Volume 14, Number 4 AmericanNurseToday.com Small bore or large bore? Chest thoracotomy tube drains are either small-bore or large-bore. aration is filling the water seal cham - ber with sterile water or sterile Small-bore drains • Size: 8.5 to 14 Fr normal saline to the prescribed • level (2 cm). As part of your safety Recommended as firstline treatment for pneumothoraces, pleural effusions, and pleural infections and contingency preparations, • keep petroleum gauze and a rub- Less patient discomfort • Less severe complications ber-tipped clamp at the patient’s bedside, especially during trans- Large-bore drains fers, in case of complications. • Size: 24 to 32 Fr Antibiotic and pain prophy- • Used for most adults laxis: Antibiotic prophylaxis is • Recommended for acute hemothorax to monitor blood loss recommended only for patients with traumatic chest injuries. In addition to 1% lidocaine injected around the incision site to reduce pain, premedication with an I.V. Tape: A little goes a long way analgesic and/or an anxiolytic is In addition to suturing, a chest thoracotomy tube recommended. (CTT) should be secured with tape a few inches be- Site selection and imaging: CTTs low the insertion site to prevent accidental dislodg- are usually inserted in the 4th or 5th ment and dependent loops. The omental tape tech- intercostal space just anterior to the nique fastens the tube securely while allowing some midaxillary line. Imaging guidance distance between the skin and the tube to prevent during CTT insertion is strongly rec- kinking and tension at the insertion site. ommended, so make sure that a func - Too many nurses think that more tape leads to tional and disinfected ultrasound ma- more secure CTTs, but the evidence doesn’t support chine is in the patient’s room before that. In addition to being wasteful and unnecessary, the procedure. excessive tape may impede chest wall expansion. It also can increase moisture collection between the Patient positioning: Optimal skin and the adhesive, which may lead to infection. Omental tape technique positioning during the procedure requires balancing the patient’s overall condition and comfort with the provider’s access to the ile gloves, drapes, and gowns. CDUs ana tomic structures. Guidelines in- Securing the tube: After inser- CDUs ensure negative pressure with- dicate that the preferred patient tion, providers secure the CTT with in the chest cavity by facilitating position is semi-reclined at a 45- heavy, nonabsorbable suture (0 or unidirectional flow of drainage degree angle, boosted by a small 1-0 silk). Dressings and tape are (pleural fluids, blood, or air) from wedge or linen to fully expose helpful, but nothing secures a chest the intrapleural space into the the side to be operated on. The tube better than stitching it in place. CDU’s collection chamber. CDUs patient’s forearm is raised above (See Tape: A little goes a long way.) are categorized according to size the head, and the hand is tucked Insertion site dressings: The and their mechanism for prevent- behind the head. Secure any other literature presents several ways of ing air and fluid from entering the potential obstructions to the sur- dressing a CTT insertion site, but pleu ra. Underwater seal CDUs are gical site, such as a pendulous little evidence supporting their ef- larger and have two chambers (a breast, before the procedure. fectiveness exists. (See Insertion drainage collection chamber and If the patient can’t tolerate lying site dressing options.) In most prac- water seal chamber). (See Under- in bed, he or she may assume the tice settings, the provider who water seal CDUs). One-way valve orthopneic position, sitting up with placed the CTT selects the dress- CDUs are smaller and more an overbed table in front to lean on ing. The nurse performs postinser- portable. (See One-way valve CDU.) and a pillow placed under the arms tion dressing changes according to Both small- and large-bore CTTs for comfort. This allows maximal organizational policy. can be attached to either category expansion of the lungs while ex- Confirming placement: An X- of CDU. The provider selects the posing the midaxillary area. ray usually is needed to confirm CTT appropriate CDU type for the pa- Aseptic technique: Guidelines placement after insertion. Studies in- tient by anticipating the amount of recommend full aseptic technique, dicate that daily chest X-rays to mon- drainage and whether suction will which includes skin cleansing, ster- itor placement aren’t warranted. be needed. AmericanNurseToday.com April 2019 American Nurse Today 11 Insertion site dressing options Underwater seal CDU The classic dressing for chest thoracotomy tube Drainage collection chamber: (CTT) insertion sites is petroleum gauze held in Drainage collection chambers, which place by a secondary dressing of sterile, 4" x 4" typically have a 2,100-mL capacity, sponge gauze secured with tape. Studies suggest have calibrations and numeric mark- that petroleum gauze macerates skin over time. ings for measuring output. Best Other dressing materials have been explored, in- practice is to mark the drainage lev- cluding dry occlusive dressings, standard gauze, and transparent film. A randomized controlled trial el and write the date and time of by Gross and colleagues found no significant differ- each reading on the face of the ence in the effectiveness of petroleum gauze, dry CDU. The provider orders output sterile dressing (bordered gauze), and no dressing. monitoring frequency, but at a min- However, the sample size was small, so the result imum, do it at the start and toward can’t be generalized. the end of your shift. Transparent film can be used alone or as a sec- Water seal chamber: The water ondary dressing to avoid using tape. It also allows better visualization of the CTT to monitor for tube CTT insertion site dressing with seal chamber prevents atmospher- transparent film on top ic air from going into the pleural migration. space. Any air in the pleural space will drain through the CTT and pass through the collection chamber and • water spillage if the CDU is Managing patients with a CTT into the water seal chamber, where knocked over If you follow a few practical tips, it appears as intermittent bubbling.
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